Join

I AM A TEEN (this registration is for me) MY TEEN (I am a parent, this registration is for my teen)

Full Name*

First Name Last Name

E-mail*

Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

High School

Graduation Year

Birthday

Month Day Year

What is your preferred method of communication?

FB Email Text Message All of the above

Two friends I would like to refer to CTeen (optional):

Friend 1

Friend 2

Size for cTeen tshirt:

Is your mom or dad Jewish?

Mom Dad Both

How did you hear about CTeen?

Please list one adult reference (e.g. School teacher, family friend).

Reference Name

First Name Last Name

Reference E-mail

Mother's Name

First Name Last Name

Mother's E-mail

Mother's Phone Number

Area Code Phone Number

Father's Name

First Name Last Name

Father's E-mail

Father's Phone Number

Area Code Phone Number

Registration:*

CTeen Membership: $150 Membership + Sponsor a teen: $300

Membership includes participation in community service programs such as volunteering at Blythedale Children's Hospital or Sports with SEC (Org. for special needs), Shabbat and Holiday events/dinners, and discounted rate for regional events and Shabbaton weekends.

Total

$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Teen's Information

Parent's Information